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General NPI Number Information
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NPI Number | 1083606610
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Entity Type | Individual
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Provider Name | JACQUELINE S SHRIVER CRNP
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Gender | Female
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Dates
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Enumeration Date | 08/19/2005
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Last Update Date | 04/19/2021
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Provider Practice Location Address
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Address Line | 1140 S KNOXVILLE AVE STE B
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City | SAINT MARYS
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State | OH
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Zip | 45885-2609
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Country | US
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Telephone | 419-394-7314
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Fax | 419-394-7313
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Provider Business Mailing Address
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Address Line | 200 SAINT CLAIR AVE
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City | SAINT MARYS
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State | OH
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Zip | 45885-2400
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Country | US
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Telephone | 419-300-1129
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Fax | 419-394-9575
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number | NP2122
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License Number State | OH
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